History and admission findings: A 36-year-old Korean had since childhood suffered from a chronic progressive lung disease, marked by dyspnoea, productive cough and recurrent sinusitis. He was in a reduced general condition on admission. There were hyperresonant sounds on palpation over both lungs, a low diaphragm and slight vesicular breath sound as well as occasional rales and sibilant rhonchi.
Investigations: Laboratory tests showed increased blood cell sedimentation of 52 mm at 1 h, leukocytosis of 24.3/nl, and a raised cold-agglutinin titre. Haemophilus influenza and Pseudomonas aerogenes were cultured from the bronchial secretion. Lung function tests revealed severe obstruction with hyperinflation and partial respiratory failure with a much reduced 1-sec forced expiratory volume (FEV1) of 0.71, 19% of normal; residual volume (RV) 6.61, 550% of normal; arterial oxygen partial pressure 61 mm Hg; arterial CO2 partial pressure 36 mm Hg. Chest X-ray showed emphysematous changes with diffuse small nodular shadows. Bronchoalveolar lavage revealed 96% neutrophils, indicating marked granulocytic inflammation. A video-assisted thoracoscopic biopsy was performed which showed diffuse panbronchiolitis.
Treatment and course: The symptoms, radiological changes and lung functions clearly improved under long-term treatment with 500 mg erythromycin daily.
Conclusion: Diffuse bronchiolitis is rarely seen outside of Asia, but it should be included in the differential diagnosis because, in contrast to other forms of chronic obstructive lung disease, it responds to long-term erythromycin medication.